Public health is about as behavioural as it gets. The leading causes of death are dominated by behavioural and lifestyle factors: smoking, diet, alcohol consumption, accidents, but also more subtle behavioural factors such as how we relate to and support each other.
The Australians have long been seen as leaders in public health. They led on advertising restrictions on smoking decades ago; more recently on plain-paper packaging for cigarettes; and their edgy and funny public health campaigns are famous the world over. Public health was also the subject of BIT’s very first, and tentative report back on New Year’s Day 2011 (the idea was to harness the timeliness of new year resolutions). So maybe it’s no surprise that Australia’s VicHealth – itself created more than three decades ago to replace revenue to sports and health from tobacco sponsorship – and BIT teamed up. This week saw the publication of the results, including more than half-a-dozen trials, the ‘TEST’ framework for building effective interventions, and more detail on a large scale deliberative jury on obesity.
Two years ago, VicHealth’s CEO Jerril Rechter’s asked if I’d be VicHealth’s inaugural Leading Thinker. I was a bit worried about how the practicalities of this would work, what with 24 hour flights etc, but with BIT’s Rory Gallagher being dispatched to help build New South Wales Premier and Cabinet’s behavioural insights capability at the same time, we thought we should give it a shot. I’m glad we did. There is something very powerful and challenging about exposing yourself to new viewpoints. Today’s edgy successes can become tomorrow’s anchor – an inadvertent driver of risk aversion.
The report launched today summarises the trials we conducted with some brilliant partners (there are too many to mention here). The trials undertaken as part of the Leading Thinkers program have looked at all manner of interventions. They include examples that illustrate all aspects of the EAST approach, applied to health and well-being:
- Easy: in a trial with the Alfred Hospital, making the most unhealthy ‘red’ drinks more difficult to reach, but still available, led to a drop in their sales by 12%, and a jump in sales of healthier drinks by 4% and 8% for the moderate and healthiest drinks respectively – importantly with no overall decline in sales. It’s a superb, and closely documented example of making it easier to make a healthy choice. As an interesting aside, Kirstan Corben, the champion of the trial within the hospital, conducted a survey of customers and found that only around 1 in 100 even noticed the change, let alone objected.
- Attractive: another extremely topical trial, also in the Alfred, tested the effect of price variations on consumption using an RCT across the hospital’s vending machines. It showed that a 20% increase in the price of the unhealthiest drinks led to a 10% fall in purchases. Interestingly, as in the canteen, the substitutions were disproportionately to the healthiest drinks (essentially bottled water).
- Social: a trial with Timboon and district tested the impact of small group collective incentives to boost physical activity (building on the work of Kevin Volpp around weight loss). The social incentives, requiring everyone in the group to reach their exercise target 5 out of 7 days, led to a more than 2,000 extra steps a week. We also tested the impact of more personalised targets within the group, and found that this boosted performance even further.
- Timely: keen to help VicHealth build its capability in running digital trials, we worked with them to test the impact on sign ups to a health challenge to Victorians, by varying how people signed up online. In a 3-arm trial, the more effective variation boosted sign-ups from 7 percent to over 11 percent.
I’ve long felt that as governments and public bodies start to use behaviourally-based interventions to affect life-style choices, they should really make sure citizens agree with those decisions and interventions. VicHealth agreed and ran an absolutely outstanding deliberative jury on obesity.
This Victoria’s Citizens’ Jury on Obesity took place over six weeks. Jurors were given more than 60 background papers on obesity from a range of interest groups, including papers prepared especially for the jury. After six weeks of online deliberation, the jurors were brought together for a weekend of discussion and debate in the city of Melbourne. The jurors then voted on experts that they particularly wanted to hear from. Towards the end of the weekend, jurors drafted, re-drafted, debated, re-drafted and then voted on which ‘asks’ that they would like to make of the steering group. To make it into the final report, ‘asks’ had to achieve at least 80 per cent support among the group. The jury’s report contained 20 ‘asks’ of government, industry and civil society. You can read the asks here. They will give some insight on how powerful getting the public to think about the issue can be, but just seeing the 20 asks written in a report hides how sophisticated the debate on the day was.
The residency has proved a powerful learning experience for both the Behavioural Insights Team and VicHealth. It wasn’t always easy. I’d particularly like to acknowledge the commitment across VicHealth, and by Jerril in particular, in taking on such an ambitious programme. It also pushed us in BIT to identify more explicitly, particularly for those from very different professional backgrounds, how to develop and implement a trial-based intervention from start to finish. It also helped to embed the ‘TEST’ framework – which we hope will be one of many lasting contributions from this joint project and report.
It’s not easy to break out of existing patterns of thought. It is hard to shift your assumptions about human behaviour; to learn how to do trials from scratch; and to run a deliberative jury on a complex, multifaceted problem. But to do all three at once is really impressive. Kudos Victorians!
We’re very excited to have established a Sydney office, where we now have a dozen staff doing cutting edge work across the country and the wider Asia-Pacific region. And with Canberra pushing forward, led by Michael Hiscox and the new BETA team (welcome!), and Premier and Cabinet in Victoria, under the experienced and impressive hand of Chris Eccles, pushing forward too, Australia is looking like a place to watch…